Updated offshore health screening
The offshore Immigration Medical Examination (IME) screening and Departure Health Check (DHC) for humanitarian entrants have been updated since 2023. Changes are outlined in the updated Department of Home Affairs (DHA) Panel Members Instructions (Jul 2024), DHC supporting material (Aug 2024) and have been implemented on the HAPlite system. Changes are listed in the pre-arrival screening section below, with implications for onshore screening noted in red*.
Health issues
New arrival refugee or asylum seeker children/adolescents will have typical paediatric health problems, and may also have health issues specific to their background or forced migration experience. Common paediatric problems, e.g. iron deficiency anaemia, may have a more complicated aetiology in these cohorts. All refugees and asylum seekers should have a full health assessment after arrival in Australia, ideally within one month of arrival.
Assessment of newly arrived refugee or asylum seeker children and adolescents should focus on:
Children and adolescents need a thorough physical examination. Particular features to note include: growth parameters (height, weight and head circumference), nutritional status, anaemia, rickets, oral health assessment, ENT disease, visual acuity, presence of a BCG scar (forearm, deltoid, other, either side), respiratory examination and lymphadenopathy, cardiac examination, hepatosplenomegaly and skin (scars, infections).
Suggested initial post-arrival screening investigations
Screening (e.g. neonatal screening, visual and hearing assessment) may have been limited or unavailable in the country of origin, and prior access to healthcare, dental care and education varies. It is important to explain the concepts of health assessment, screening and disease prevention. Families need to understand the implications of health screening and give informed consent; this means explaining all tests, conditions being screened, the meaning of a positive test, and next steps in management. Individual counselling and an explanation of confidentiality are required in adolescents.
The following list includes suggested first-line investigations, based on the 2016 Refugee Guidelines from the Australasian Society for Infectious Diseases (ASID) and Refugee Health Network of Australia (RHeaNA) and updated for Afghan, Ukrainian, Gazan and Rohingyan arrivals. Additional investigations may be needed depending on the clinical scenario.
All children and adolescents
- Full blood examination/film
- Ferritin
- Hepatitis B serology - surface antigen (HBsAg), surface antibody (HBsAb) and core antibody (HBcAb) *HBsAg not required if completed & negative result offshore, reasonable to vaccinate without cAb/sAb, check serology in household contacts of HBV cases
- Strongyloides serology (*not Ukraine) *still indicated if offshore ivermectin
- Tuberculosis (TB) screening - tuberculin skin test (TST) or interferon gamma release assay (IGRA). TST preferred in children
<5y. *If recent (3-6m) negative IGRA 5y and older completed offshore and no exposure history - reasonable to use this result, low threshold to repeat
- Faecal specimen - cysts, ova parasites (COP, ideally fixed to improve detection of protozoa), depending on pre-arrival albendazole, and eosinophilia
- If documented pre-departure albendazole:
- No eosinophilia - no investigations
- Eosinophilia - COP and directed treatment
- If no documented pre-departure albendazole:
- Empiric single dose albendazole (>6m,
<10kg 200 mg; 10 kg+ 400 mg). If baseline eosinophilia repeat FBE at 8 weeks, and if persisting COP and directed treatment OR
- COP and directed treatment, repeat FBE and COP at 8 weeks
- *Parasite screening/treatment recommended for arrivals from Gaza and Rohingyan cohorts; not required for arrivals from Ukraine.
Age-based or risk-based screening
- Vitamin D, calcium, phosphate, ALP - risk factors for low vitamin D, all Afghan and Gazan arrivals, see
Medicare guidelines for vitamin D testing
- Serum active vitamin B12 & folate - arrival
<6m and any of food insecurity, vegan, Afghanistan, Gaza, Bhutan, Rohingyan, Iran, Horn of Africa. Also check homocysteine and urine methylmalonic acid if risk low B12 and disability or neurological symptoms
- MMR and Varicella serology - consider in adolescents to determine vaccination *also reasonable to vaccinate without serology
- Schistosoma serology - travel from/through endemic area. Endemic: Africa, Burma, Bangladesh (Rohingyan), Iraq and Syria; not other Middle East/Afghanistan/Ukraine/other Asian countries. *still indicated if offshore praziquantel
- Malaria screen (rapid diagnostic test (RDT) and thick/thin film) - arrival date
<3m from endemic area, or later if symptoms. Endemic: Africa (except Egypt), Burma, Bangladesh (Rohingyan), Thailand, Cambodia, Bhutan, India, Pakistan, Afghanistan, Venezuela, not Middle East/Egypt/Sri Lanka/Ukraine, *not required if well and recent negative result offshore
- Hepatitis C serology (Hepatitis C virus (HCV) antibodies) - if from
endemic area or if risk factors. Endemic: Congo, Egypt, Iraq, Pakistan, Rohingyan cohorts, consider in Syria, Ukraine; not other African/Middle East/Afghanistan/Asian countries *not required if negative result offshore
- Hepatitis A serology - all Gazan and Rohingyan arrivals until more information available on this cohort
- HIV testing - age 15y+, unaccompanied or separated minor, or clinical risk factors (sexually active, history of sexual violence/abuse, where parents are deceased/missing/known to be HIV positive, other STIs, history of blood transfusions, tuberculosis, hepatitis, or where there are clinical symptoms/signs)
- STI screen (HIV, syphilis, urine nucleic acid detection N. gonorrhoea and C. trachomatis, consider rectal/throat swabs) - if risk factors, and if there is a history of sexual violence/abuse
- Syphilis screening - all unaccompanied or separated children; children should also be screened for syphilis if their mother has positive serology
- Helicobacter pylori screening (faecal antigen test on fresh specimen) in children with family history gastric cancer, or symptoms/signs dyspepsia/ulcer disease.
Additional investigations to consider
- Additional investigations for malaria and other infections in recently arrived children who are febrile and unwell
- PTH in children with inadequate dietary calcium intake, signs/symptoms of low vitamin D, or multiple risk factors for low vitamin D
- PTH, urine calcium/phosphate/creatinine, CUE, wrist X-rays (and X-rays of leg deformity if present) in children with clinical rickets (as well as vitamin D related tests above)
- Nutrition screening (i.e. FBE, ferritin, vitamin D-related, B12/folate (as above); also vitamin A, C, E, zinc, TFT, carnitine,
other tests - see details) in children with restricted food access pre-arrival, exclusively breastfed babies with poor maternal food access, or where deficiency is suspected clinically. Low vitamin A has been common in children from Gaza, B12/folate deficiencies reported in refugees from Afghanistan, Bhutan, Middle East, Gaza and Sri Lanka. Recommend vitamin A and zinc screening (+/- other nutrition screening) in all new arrivals from Gaza and Rohingyan cohorts.
- Thyroid function tests in any child with developmental delay (usually appropriate to delay genetic testing, and this can be completed later using saliva testing)
- Blood lead levels in all children from Gaza and Rohingyan cohorts until further information, in children with pica or developmental issues, or where there is a history suggesting exposure, including through traditional medicines (including thanaka use in Myanmar/Rohingyan cohorts). Blood lead screening is not routine in Australian refugee guidelines, but is
recommended in US refugee guidelines (for all children 6m-16y, older adolescents with clinical risk and all pregnant/breastfeeding women).
Other considerations
Screening (or partial testing) may have been completed by other providers. Victoria moved to a primary care model for refugee health screening from around 2006. Current data suggest <10% children receive recommended screening in this model, and ~25-30% receive partial screening. Every attempt should be made to access screening that has been completed and avoid duplicating investigations. Also see Department of Health and Aged Care information on health assessments.
Asylum seeker children received very little screening in detention prior to mid-2014 (essentially only history, public health checklist, and TB screening if known contact history). See details on pre-arrival screening below. In 20 years, we have never seen an unaccompanied humanitarian minor (UHM) who has completed recommended screening.
Pre-arrival screening
All permanent migrants to Australia have an IME within 3-12m of departure (see Panel Members Instructions & pdf form for quick view). The IME includes:
- Full medical history and examination all
- Chest x-ray (CXR) age 11y+ (and in younger children if indicated)
- IGRA or TST children 2-10y (if they: are applying for a Humanitarian or onshore protection visa, OR from a high TB prevalence country, OR declare previous household contact), with further investigation for TB if positive (from 2016)
- Serum creatinine and estimated GFR age 15y+ (and younger if indicated)
- HIV testing (EIA + confirmation if positive) age 15y+ (and younger if indicated), all international adoptees, UHM, intending healthcare workers, or where intravenous drug use, HCV infection or tuberculosis are identified
- HBsAg in all pregnant women, international adoptees, UHM, intending healthcare workers, clinical indications, offshore humanitarian applicants 15y+ (new) and those 15y+ applying for an onshore protection visa, or where HCV infection is identified
- HCV antibody tests if clinical indications, all intending healthcare workers, offshore humanitarian applicants 15y+ (new) and those aged 15y+ applying for an onshore protection visa, or where HBV or HIV infection are identified
- Syphilis screening (VDRL or RPR, + confirmation if positive) age 15y+ and applying for either an onshore or offshore protection visa
- Other tests as clinically indicated.
Humanitarian entrants are also offered a free voluntary DHC. This usually occurs within 72 hours of intended departure for Australia, but may be conducted up to 4 weeks before travel. Not all humanitarian entrants undergo a DHC, although uptake is high (and likely to increase). The DHC includes:
- Clinical consultation and physical examination, including mental health screening
- Review of IME TB screening results; CXR if: history of treated/inactive TB, clinical suspicion of active TB disease, immune compromise, household contact since IME
- Pregnancy testing offered to women of child bearing age
- Measles, mumps and rubella (MMR) vaccination in age >9m (unless pregnant/medical contraindication/born before 1966)
- Yellow fever (YF) vaccine (or review of YF certificates) where relevant in age >12m (based on location)
- Polio vaccination - our clinical experience suggests increasing use of hexa- or pentavalent vaccines in children
- Malaria RDT, and treatment if positive, generally with 3 days of oral artemether/lumefantrine (based on location - sub-Saharan Africa, India, Bangladesh, Pakistan, Afghanistan, Burma, Thailand, Indonesia, Cambodia, Venezuela, PNG, Solomon Islands)
- Parasites - empiric treatment for:
- Soil transmitted nematodes with albendazole age 6m+ (not pregnant, age <6m, unexplained seizures or signs neurocysticercosis)
- Strongyloides infection with ivermectin where prevalence is presumed to be high (10%+): East Asia, Pacific, sub-Saharan Africa, Latin America (not pregnant, early breastfeeding, weight <15kg, Loa loa areas)
- Schistosoma infection with praziquantel in endemic areas: Venezuela, sub-Saharan Africa, including Democratic Republic of
Congo, Central African Republic, Eritrea, South Sudan and Ethiopia (not pregnant, breastfeeding, age <12m, unexplained seizures or signs neurocysticercosis).
Changes to IME and DHC (2023)
Recent changes to the IME and DHC include:
- IME
- Addition of Hepatitis B sAg screening in all refugee entrants 15y+ (and younger if clinical indications)
- Addition of Hepatitis C screening in all refugee entrants 15y+ (and younger if clinical indications)
- Addition of serum creatinine and eGFR age 15y+ (and younger if clinical indications)
- Improved vaccination records - including past vaccines and more comprehensive vaccination as part of the offshore IME and DHC
- Improved use of the functional assessment tool - which is practical and useful for people with disability
- DHC
- Making the DHC free for all humanitarian entrants
- Clearer consideration of pregnancy status - check of pregnancy status/gestation, consideration in all immunisation/parasite protocols, and implementation of post arrival alert for all pregnant women to ensure post arrival care
- Review of vaccination history (also uploading past immunisation records +/- additional vaccinations)
- Clearer direction on recording medications and medication supply (ideally 4 weeks)
- Expanded malaria screening areas
- Empiric treatment of parasite infections (adjustments to albendazole age/dosing, and introduction of ivermectin and praziquantel for some ports of departure as above)
- Changes to the health alert system (as of Jan 2025), now to 24 hours (+/- health escort cases), 1 week (for conditions with potential to deteriorate after arrival) and 1 month (general follow-up).
Asylum seeker health screening
- People seeking asylum who arrived by boat generally received a health assessment on arrival in immigration detention, completed by the detention health services provider. There is no published information on the format of detention health screening; however, assessment included: CXR age 11y+ and screening bloods in age 15y+ (syphilis, HBsAg, HCV and HIV reflecting the offshore IME; and FBE, LFT, BSL, urinalysis and pregnancy testing where clinically indicated). Prior to mid-2014, children had very limited detention health screening. After this time they had health assessments similar to adolescents and adults, with the addition of ferritin, vitamin D levels, Strongyloides serology; and malaria testing and Schistosoma serology where clinically indicated. Clinical experience suggests the management of health conditions detected on the detention health assessments varied widely, and was often deferred while awaiting transfer to community-based arrangements.
- Asylum seekers arriving by plane may not have had any health screening or healthcare in Australia and will not have had a pre-departure IME.
- People seeking asylum are required to have an IME at the time they are granted a substantive visa (including at grant of temporary protection visa) - see
arranging a health examination and
health examinations for temporary visas.
Resources
Immigrant health clinic resources, Author Georgie Paxton, Updated 9 Jun 2025, Contact: georgia.paxton@rch.org.au